Reducing HIV-related stigma: lessons learned from Horizons research and programs

Since the early years of the human immunodeficiency virus (HIV) epidemic, stigma has been understood to be a major barrier to successful HIV prevention, care, and treatment. This article highlights findings from more than 10 studies in Asia, Africa, and Latin America-conducted from 1997 through 2007 as part of the Horizons program-that have contributed to clarifying the relationship between stigma and HIV, determining how best to measure stigma among varied populations, and designing and evaluating the impact of stigma reduction-focused program strategies. Studies showed significant associations between HIV-related stigma and less use of voluntary counseling and testing, less willingness to disclose test results, and incorrect knowledge about transmission. Programmatic lessons learned included how to assist institutions with recognizing stigma, the importance of confronting both fears of contagion and negative social judgments, and how best to engage people living with HIV in programs. The portfolio of work reveals the potential and importance of directly addressing stigma reduction in HIV programs.

Improving the lives of vulnerable children: implications of Horizons research among orphans and other children affected by AIDS

From 1997 through 2007, the Horizons program conducted research to inform the care and support of children who had been orphaned and rendered vulnerable by acquired immunodeficiency syndrome in sub-Saharan Africa. Horizons conducted studies in Kenya, Malawi, Rwanda, South Africa, Uganda, Zambia, and Zimbabwe. Research included both diagnostic studies exploring the circumstances of families and communities affected by human immunodeficiency virus (HIV) and evaluations of pioneering intervention strategies. Interventions found to be supportive of families included succession planning for families with an HIV-positive parent, training and supporting youth as caregivers, and youth mentorship for child-headed households. Horizons researchers developed tools to assess the psychosocial well-being of children affected by HIV and outlined key ethical guidelines for conducting research among children. The design, implementation, and evaluation of community-based interventions for orphans and vulnerable children continue to be a key gap in the evidence base.

Addressing gender dynamics and engaging men in HIV programs: lessons learned from Horizons research

In the field of human immunodeficiency virus (HIV) prevention, there has been increasing interest in the role that gender plays in HIV and violence risk, and in successfully engaging men in the response. This article highlights findings from more than 10 studies in Asia, Africa, and Latin America--conducted from 1997 through 2007 as part of the Horizons program--that have contributed to understanding the relationship between gender and men's behaviors, developing useful measurement tools for gender norms, and designing and evaluating the impact of gender-focused program strategies. Studies showed significant associations between support for inequitable norms and risk, such as more partner violence and less condom use. Programmatic lessons learned ranged from insights into appropriate media messages, to strategies to engage men in critically reflecting upon gender inequality, to the qualities of successful program facilitators. The portfolio of work reveals the potential and importance of directly addressing gender dynamics in HIV- and violence-prevention programs for both men and women.

Risk and protective factors for HIV among orphans and non-orphans in Tanzania

The objectives of this study were to identify risk and protective factors for engaging in unsafe sex among orphans and non-orphans and to explore whether risk and protection differs by gender and orphan status. The study was carried out in Kisesa ward, in the Mwanza region of Northwest Tanzania. A combination of in-depth interviews and focus group discussions were used to collect data from girls and boys as well as from the female caregivers of orphans. Findings revealed that among young people who reported having unsafe sex, those who were female orphans were more likely to state that they 'had to have sex' to acquire food and clothing for their households. Caregivers believed that many young people who engage in sexual-risk behaviours do so because they are not provided with adequate supervision and moral guidance. The study suggests that programmes may need to target both girls and young women and their caregivers and create access to education and decent work opportunities.

Lack of effect of rifalazil on ethinyl estradiol pharmacokinetics in healthy postmenopausal women

Rifalazil, a second-generation rifamycin, is being evaluated for the treatment of sexually transmitted disease and gastrointestinal infections. We determined whether rifalazil influences CYP3A4 metabolism by studying the effect of a single oral, 25 mg dose of rifalazil administered to healthy postmenopausal women, on the steady-state pharmacokinetics (PK) of ethinyl estradiol (EE) during administration of Ortho-Novum 1/35 (EE/NET). Noncompartmental PK and sequential statistical analyses were performed to establish if and when subjects achieved steady-state EE plasma concentrations and to determine whether this steady state was altered by rifalazil administration. The geometric mean ratios for the difference between EE alone and following rifalazil for EE Cmax, AUC(0-24) and Cmin were 105.9, 104.4 and 105.0, respectively. The 90% confidence intervals for each ratio fell within 80 - 125% of the reference treatment indicating no significant difference in the PK of EE before or after rifalazil administration. The posterior probabilities for the true treatment differences of Cmax or AUC(0-24) being less than 20% were > 99.99% in both cases. Based on the results of this study, there is no CYP3A4-metabolic interaction between a single oral, 25 mg dose of rifalazil and EE for either induction or inhibition. Consequently, there is minimal threat of contraceptive failure when single doses of rifalazil are administered with EE/NET. A single dose of rifalazil 25 mg was well tolerated when administered concomitantly with a combination oral contraceptive (EE/NET) by healthy postmenopausal females.

Effect of food on the pharmacokinetics of rifalazil, a novel antibacterial, in healthy male volunteers

Rifalazil is a new antibiotic structurally related to rifampin but devoid of the metabolic liabilities typically associated with the rifamycin class of antibiotics. A randomized, 3-way crossover study in healthy male volunteers (n = 12) investigated the safety and pharmacokinetics of a single 25-mg oral rifalazil dose administered under a standard breakfast containing fat as 30% of calories, a high-fat breakfast containing fat as 60% of calories, and an overnight fast of 10 hours with a 21- to 28-day washout between doses. Systemic exposure to rifalazil based on Cmax, AUC(0-Tlast), and AUC(0-infinity) was increased progressively as the fat content of the test breakfast was increased from 30% to 60% compared with fasting. The confidence intervals for both fat-containing breakfasts are outside the limits of 80% to 125% allowed for food effect bioequivalence based on Cmax, AUC(0-Tlast), and AUC(0-infinity). This food effect may be a result of increased fractional absorption with increasing dietary fat content. Another striking finding was the large reduction of the pharmacokinetic intersubject variability after rifalazil administration with food. Rifalazil was safe and well tolerated under fed and fasted conditions.